PSA recommendations - is it sexism?

Sorry for the significant delay in blog posts.  It's been a long couple of months at DuPage Family Medicine.  We were forced to terminate the services of a long-time employee, all while having to deal with a 6+ week disruption in our phone service.  It's been a stressful couple of months, but we are starting to see the light at the end of the tunnel, and it's time for me to start writing again.

Last week, the U.S. Preventive Services Task Force (USPSTF) recommended against the use of prostate-specific antigen (PSA) testing for routine screening for prostate cancer.  The USPSTF states that the risks of screening outweigh the benefits, arguing that certain treatments for prostate cancer can actually increase mortality.  Other arguments against PSA testing include the morbidity associated with the diagnosis and treatment of prostate cancer, such as impotence and incontinence, as well as the emotional stress a false-positive test can cause the patient.

In my practice, I begin doing prostate exams at age 40 on all men.  PSA testing usually begins at age 50 for low risk men.  For higher risk patients, I begin screening at age 45. These patients are men of African-American heritage and men who have a family history of prostate cancer in a first degree relative (brothers or father).  Using these guidelines, I have diagnosed 7 men with prostate cancer under the age of 50, about one patient in this age group every 2 years.

A few years ago, the USPSTF recommended against the use of annual mammography to screen for breast cancer in women.   There was immediate backlash from the public and physician groups.  That recommendation was based on statistics and data that showed that annual testing led to more procedures, and didn't necessarily improve outcomes, almost exactly the same argument against PSA testing.  The public outcry over the mammogram recommendations was loud and clear, but unfortunately, there hasn't been the same kind of backlash against the new PSA recommendations.  I find that extremely disappointing.

It is unfair to recommend against the only screening test men have for prostate cancer, even if it has drawbacks, when a similarly mediocre screening test continues to be a mainstay of diagnosis for breast cancer in women.   We need to support researchers to find better screening tools for all cancers, not just prostate and breast.  Specifically speaking of prostate cancer, if researchers can give us a test that can tell the difference between a slow growing cancer and an aggressive one, we can eliminate a large number of invasive surgeries, significantly decreasing the morbidity of excessive treatment.

I respect the USPSTF and most of their recommendations.  They tend to be conservative, with recommendations that are based on the data. The problem with the new PSA recommendation is that we don't have an alternative.  Just because some of the treatments for prostate cancer lead to increased morbidity doesn't mean you eliminate the use of the only screening test we have available.

I am planning on implementing the recommendations as follows.  For any patient with an abnormal exam (enlargement of gland, asymmetry, etc), they will continue to get annual PSA levels independent of age.  For low risk patients and men with stable prostate exams, I will do PSA levels every 2 years.  All of this will be dependent on the patients comfort level.  If they want an annual test, then we'll order it.

Recommending against PSA testing, yet continuing to recommend mammography, seems a bit, dare I say, sexist.  But then again, I'm a guy.

The argument for drug samples

Over the last few years, the pharmaceutical industry has gone through significant changes.  The days of free trips and rounds of golf are long gone (I'd be lying if I said I didn't miss the occasional round of golf on the drug rep's tab).  There has been significant consolidation, with larger companies purchasing smaller ones, leaving the landscape with just a few mega-companies who call on physicians,  detailing us on their products - the medicines we prescribe.

There have been many arguments against physicians giving out free "samples" of pharmaceuticals.  I understand what the experts say.  They argue that in the end, the free medicine costs patients more because we have a tendency to hand out the free, more expensive branded product before we consider cheaper alternatives.  They argue that visiting with cute (or handsome) drug reps will change the way we prescribe, specifically, that we will prescribe more of that sales reps product.  They argue that Big Pharma has built in so much profit into their branded medicines that the free samples are a drop in the bucket, and that even one new script will bring in profit enough to support the "hard sell" we doctors get from the reps.

I completely understand these arguments.  There is some validity to them.  However, I feel the need to offer some retort.

With so many excellent generic medicines available, a physician would have to be really disconnected from their patient to not reach for a generic first.  We may not like this, but with deductibles continuing to rise, we are stewards of our patients health care dollars.  It is in our best interests, outside of being incentivized to do so, to be as cost-effective as we can.  This is true for all aspects of our job, whether it's medicines, test ordering, frequency of medical visits, et cetera.

My biggest concern about turning off the samples is that there are some excellent new medicines that have come on the market that physicians will be less likely to try if they don't take samples or see reps.  It's not easy for us to learn about new classes of medicines.  If I didn't visit with reps, I suppose I could go to a symposium, corner a colleague at the hospital, or ask a local pharmacist.  Don't you think it is a little easier to have a brief conversation with a sales rep who can give you a 2 minute spiel, and leave some science behind?

Having samples allows me to test-drive some of these new therapies.  I can give 2, 3, or 4 weeks of samples to a patient to see how they respond to the therapy.  During this time, they can call their insurance to check on their out of pocket costs.  I always let the patient decide if the medicine is worth their cost.  In particular, with certain diabetes medicines like the new DPP-4 inhibitors, I will make a hard sell, because I truly believe that the cost is worth it.  These new therapies don't have the dangerous side effects some of their older generic counterparts have.

I have a well organized sample closet in my practice.  Honestly, we dispose of expired samples in at least a 6:1 ratio of samples we give to patients.   If a patient fails generic therapy, or, if your professional opinion is that a branded medicine is a better choice, let the patient take the new medicine for a spin, before they drop $35 on a branded co-pay.

We just need to put our patients first.  Period.  Be the smartest guy on the block.  Use your training and expertise to decide if you think a new therapy has merit, not the gleaming smile across the front desk or the Moo Goo Gai Pan they bring for lunch.  Explain your decisions about the medicine you are prescribing to the patient.  They'll understand.   Remember, we are supposed to be our patients advocates.  Let's behave like it.

Add it up

R. came in for a physical last week.  I've cared for him and his family for years.  They are the the type of family FPs love - nice, funny, engaging, cute kids.  R is in his early 30s and drives a truck.  Pretty healthy guy for the most part, except for one problem.  He weighs 325 pounds.

After a few minutes of chit chat, I asked him if there was anything on his list he wanted to address.  He said he was tired of being overweight, and he was looking for some guidance on how to begin losing weight.  You could sense that his weight has begun to bother him, not physically, but emotionally.  He seemed genuinely ready to lose weight, so we began our discussion in the usual place,  talking  about his diet.

I usually begin these kind of discussions asking about the typical "empty calories" that people take in, so I asked R about his soda intake.  R admitted that he drinks 2 Cokes per day.  "2 Cokes per day" can mean anything, so I questioned him further, and  it turns out he drinks 2 large Cokes per day, bought from one of the major  fast food chains, the one that has $1 sodas, any size.   He said he does this every day.  Even weekends.

I went online to try to find out how many ounces were in a large Coke from the above chain.  It turns out that a large Coke is about 24 ounces (2 cans), if one adds ice.   So, he was drinking the equivalent of 4 cans of Coke daily.

A can of Coke has 140 calories.  So, R takes in 550 (rounded) empty calories every day.  When I told him this, he didn't look at all concerned.  We then talked about the number of calories men should consume per day.  Usually, men should consume 2000-2200 calories per day.  He still didn't seem to get it.  That is, until I did the math.

550 empty calories, every day, is 16,500 extra calories per month.  He is taking in 8 extra days of calories each month just in Coke.  Let's just say that this got his attention.  His jaw literally fell open.

I guaranteed him that if he could transition from regular Coke to something like Coke Zero, he would lose 10-15 pounds, without making one other change to his diet or exercise regimen (which was non-existent).   In 3 weeks, I'm going to go through starch reductions, increasing his protein intake, and how to eat healthy (speed of eating, water intake, snacking, etc.).  We should be able to get him under 300 pounds by Halloween.

Small changes seem just that, small.  But if you add up those changes over time, they will make a big impact.  So, if you are looking to make changes in your diet (or any behavior for that matter), start with something small and be consistent.  It will definitely make a difference.

Free advice to Big Box practices

We see about 40 new patients a month in our practice.  We've done this for years, without advertising.  We rely on the word of mouth of our patients and referring specialists to build our practice.  It's been a successful approach so far.

When I first meet a new patient, I ask them about how they heard about our practice.  The majority are referred by either friends or family.  Once I've established some repoire, I'll explain my practice philosophy, some of the history of the practice, and how the hierarchy of my practice is designed.  I make a point to tell patients that I am their physician, and that by coming to a small group, they will always either see me or my physician assistant Karla.

It never gets old to see how new patients respond to this.  They almost seem relieved.  I had one patient say to me, "Finally! I'm sick and tired of seeing every other doctor or assistant than the one that's supposed to be my doctor".  You hear this enough times from enough patients, and sooner or later, you come to the conclusion that the paying public is looking for something more than what they are getting.

The majority of our new patients are former customers of the Big Box Practice (BBP going forward) which has locations throughout the western suburbs of Chicago.  I have some fairly strong opinions about the way BBP does business, but in this post, I want to focus on the patient, specifically the patients who have left BBP as unhappy customers.

The number one complaint I hear from our new patients is that they "felt like a number" at the Big Box.  This criticism is a reflection on the business model that large medical practices have adopted.  Physicians simply want to dilute their duties among as many "partners" as possible, even if it means alienating the most important piece of the equation, the patient.

Primary care medicine should always be built on the long-term relationship of a physician and patient.  If you notice, the word "physician" in the last sentence is singular.  There is no feasible way to provide insightful care without getting to know your patient, and the only way to get to know your patient is for the physician to see and care for them, not their seven partners.  Patients shouldn't tell their friends and family, "I'm a patient of Big Box Practice".  They should say, "I'm Dr. (insert name here)'s patient".

So, as a small practice physician, I'm going to give BBP a free consultation.

First of all, it's OK to have a large group of physicians.  What you need to do is make that large group feel intimate, and that starts by having your physicians take ownership of their patients.  As important as it is for patients to identify with a specific physician, it's equally important for the physician to identify with their patient.  To do this, you need to break the large group into smaller parts.

It's not that hard.  If you have 8 physicians, split into four 2-physician groups.  When one physician is on vacation, the other physician can cover, and vice-a-versa.   When you shrink your practice down into manageable parcels like this, call becomes easy.  Trust me - I've done it for years.  We take care of 6000+ patients, and I'm lucky to get one call a night during the week.  On the weekends, divvy up the hospital call amongst the 8 of you.   Patients completely understand your need for some down time.

What this will do will be amazing.  Your patient attrition will slow down, patient satisfaction will soar, and  you will start to like medicine again.  I'm not say all physicians are unhappy working for BBP, but I can tell you that how they practice medicine isn't what they imagined when they went to medical school.  I take great pride that my patients are my patients.  I am protective of them.  I work harder for them.  I am accountable.

BBP docs, don't hide inside the big groups you have built.  Re-design the way you deliver care.  I understand if you do this, I may see less new patients coming my way.  That is completely fine with me.  It will mean that your patients are happier, and getting the care they deserve.  It will mean that your patients no longer feel like they are just a number.

Like I said, this consult is a freebie.  I'd be happy to talk about my going rate if you need any other advice.

The value of a good sports physical

Our office has been busy the last few weeks pounding through our annual rush of school and sports physicals.  I really enjoy this time of year, because it gives me a chance to catch up with kids who've been healthy over the past 12 months and haven't been in to see me.  It also gives me an opportunity to really dig through any issues they may have had over the past year, especially any red flags for sudden cardiac death.

About 1 in 100,000 students will die from sudden cardiac death every year.  Every time I hear or read about a student athlete who died suddenly, I think to myself "Somebody cleared that kid to play sports".   There is no way we can prevent every case of sudden cardiac death in youths, but we can definitely prevent a few of them by doing a comprehensive annual exam.

These exams focus particularly on obtaining a thorough history from the student and their parent(s).  We ask questions about chest pain, lightheadedness, and shortness of breath, either at rest or with exertion.  Other important parts of the history include fainting, almost fainting, decrease in exercise tolerance and updating the patient's family history regarding any family members who have died suddenly.  The encounter also give us a chance to talk about concussions, physical and emotional development, academic successes and family life.  On physical examination, all patients require a thorough cardiac exam and evaluation for conditions such as Marfan's syndrome, which can lead to sudden cardiac death.

There is no possible way to do this type of clearance exam on a child/adolescent  in 5 minutes.  Unfortunately, there are parents who utilize this type of sports physical to clear their child to participate in sports.   There are walk-in clinics just up the street from my office who offer these "convenient" exams for $30.  I implore all of you to avoid this.

Take your child to his or her physician for a full well-child exam.  It only takes about 15 minutes.  The exam will  reinforce your child's relationship with their physician, and it will give you peace of mind that a trained professional has determined your child is safe to participate.

One child dying from a preventable condition is one too many.

The burden of dying

I discharged a 20 year old patient of mine from the hospital a few weeks ago.  He's the second college aged kid I've cared for with a malignant brain tumor.  T passed away in March after a 4 year fight.  T's tumor was operable, thank goodness, so we were able to buy him some good time.  K's unfortunately isn't.  His recent stay was for a complication of his cancer, and he required 2 major surgeries. It was really awful.

At one point during K's recovery, he looked like a beaten kid.  He was exhausted.  I asked him how he was doing, and he curtly said "Fine".  I said "No you're not.  I wouldn't be either".  After I checked him over, his mom followed me out of the room.   She asked me a few questions, and went back in to be with her son.  She was smiling, engaging, uncomfortably upbeat.  Throughout his stay, she didn't show a single crack in her emotional foundation.  Her matter of fact approach to her son's illness has made me realize that she hadn't had the opportunity to wrap her emotions around what her son was going through.  She needed to be strong for him, even when he wasn't.

T was the first young person I had ever diagnosed with cancer.  I remember the night I diagnosed him like it was yesterday.  Each experience he and his family went through was a new experience for me as well.  It was a privilege to watch him battle.  He was beyond inspirational. Out of all those experiences, the most surprising was how T's mom responded to her son's illness.  Even when he was done fighting, she kept him going.  It was an amazing thing to watch.   The last time I saw him, he said, "I'll see you again, don't worry".  His eyes said something different.

You could see the burden on him.   He knew his days were numbered.  As much as he wanted to wave the white flag, he couldn't, because his mom wouldn't let him.  Her ability to fight for her child was the most instinctual thing I've ever witnessed.  It came from the depths of her DNA.  This ability, to fight till the end for her child, had to be unbelievably difficult on her.  I can't imagine either of their burdens.

K hasn't stopped fighting.  But when he does, I don't think he's going to have the heart to ask him mom to stop fighting.  T couldn't.  T's love for his mom allowed him to carry her burden as well as his own.  Who knows how many other people's burdens he put on his broad shoulders?  Maybe his ability to carry the extra weight was also buried somewhere deep in his code.  Then again, maybe it came from above.  Either way, he carried the weight with incredible dignity.

Being part of these kids lives has given me such an appreciation for the strength of our bonds to one another.  Keep both of these families in your prayers.

Let's get together, and feel all right

Happy 4th of July everybody.  It's a beautiful morning here in Chicago.  I got up early to see my patients in the hospital, and now I'm home.  Kids are up, and the house is getting busy.  Life is grand.

Looking through my expansive iTunes library, I decided to stream Bob Marley "Legend" to my stereo while I worked around the house.  This album is beyond reproach.  There are few artists who's songs can elicit emotion in people from all walks of life.  The human race is better because he blessed us with his gift.

Not many people know how Bob Marley died.  Most assume it was drug related.  He actually died of melanoma at the age of 36.  He injured his toe playing soccer, and when it didn't heal, he had it biopsied.  Once he was diagnosed, the toe was amputated, but by that point, the melanoma had spread.  Within 6 months, he was gone.

All those years in the Jamaican sun, shoeless, with the tops of his feet pointing skyward took its toll. So this sunny 4th of July weekend, wear your sunscreen.  Everyone.  I don't care how dark your skin is.  Protect yourself.  It will allow you to enjoy life to it's fullest.

God Bless!

A good use of health care dollars

According to recent statistics from the American Diabetic Association, 25.8 million Americans have diabetes mellitus, a condition where the body does not process glucose, or sugar, efficiently.  Instead of glucose making it's way into cells, it stays in the blood stream, causing a slew of medical problems over time, including but not limited to blindness, kidney failure, heart disease and vascular disease, which increases risk of amputation.

The cost of diabetes in America is staggering.  In 2007, the cost of providing care for this disease was $218 billion dollars.  That is not a typo.  To put this in perspective, heart disease in 2009 cost us $316 billion (and is a complication of diabetes), and cancer care in the U.S. is expected to reach ~$160 billion by 2020.

The incidence of diabetes in America is increasing, so the above statistic is just the beginning.  Americans are more and more sedentary (both at home and at work), and our diets are high in starchy foods, such as pizza, pasta, rice, potatoes and breads.  We have trended away from preparing our own meals, instead opting for fast food.  Our intake of fruits and vegetables isn't enough, and when we do eat them, it's usually with a caramel dipping sauce or ranch dressing.  It's not good.

Once someone becomes diabetic, I aggressively educate them on behavior modification.  Exercise more, even if it's going for a long brisk walk.  Cut back on those starchy food, and replace them with more proteins or veggies.  Drink more water.  Really count your calories for a few days, just to see how much you are eating (people are usually amazed they are eating as much as they are).  Information is power, and once you show the patient the data, it really can change their behaviors.

Part of that data is blood glucose testing.  Each physician is different, but I tell my patients to check their fasting morning sugars, before breakfast, and the to check 2 hours after meals, to see how high their numbers go.  If their sugars are really high, they can correlate that high number with what and how much they ate.  It's pretty easy.

Data is king in this disease, and it brings me to the crux of this post.  The cost of testing.

I am simply amazed at how much diabetic testing supplies cost.  For some of my patients, the cost of testing is significantly more than the cost of their medicines.  I have patients tell me regularly that they don't test their sugars as much as they would like because of the cost.  This simply is unacceptable.

Data is a funny thing.  It's just information.  It lacks emotion.   That changes when the data comes from a drop of someone's blood.  It's a snapshot of how someone "is".  When patients see their how abnormal their blood sugars are, they respond emotionally.  They feel bad about it, ashamed, angry.  They take it personally.  This emotional reaction becomes a powerful tool for change, specifically, behavioral change.   Once patients improve their behaviors, their blood sugars also improve, and it feels good to see that objective change in their data.  It's positive emotional reinforcement.

I challenge the system to provide testing supplies to all diabetics.  For free.  No strings attached.  If you remove the financial disincentive to testing, patients will be more apt to do it.  In order to make a dent in the end cost of this disease, we need to improve the access of diabetics to their own blood sugar data.  I would expect the cost savings to be significant.  Improved glycemic control means fewer heart attacks, amputations, dialysis and blindness.  It's not rocket science.

There isn't a reason why this simple plan couldn't be put into place immediately.  Big Medicine - are you listening?

Drug seeking - a lesson in creativity

After 14 years of private practice, I think I've seen my fair share of the unbelievable.  This week, I saw something new.  A patient misspelled their name when they registered with our office.  On purpose.  You'll understand the importance of this is in a minute.

In April, Karla, my physician assistant, saw a new patient who came in for a visit.  He had moved to Illinois from out of state, and based on his medication list, we knew this patient was going to need careful monitoring.  He was on a significant amount of narcotics and anxiety drugs.   Karla came to me for guidance, and we decided that based on the sheer amount of narcotic he was taking (80+ milligrams a day), he would need to get his prescriptions through a pain management physician.  So, we gave him some names, asked him to let us know when he secured an appointment with the pain specialist, and sent him on his way.

He called 2 weeks later, saying he was going out of state and was afraid of running out of medicines.  He said he had an appointment with the pain management doctor for when he returned.  So, I refilled his medicines, but just one time, and made it clear to the patient I wouldn't refill them again.

This past week, we received a fax from a local big-box pharmacy, with a list of prescriptions filled by the above patient, from 5 different physicians in the last 12 weeks.  Narcotics, anxiety drugs, sleep medicines.  And there was my name, scattered amongst the other physicians who were prescribing for him.  The pharmacy was notifying us they wouldn't fill any further prescriptions for the patient, because he was getting the same medicine from multiple prescribers.

The list which was faxed to us is from the Illinois Prescription Monitoring Program.  Controlled medicines, like narcotics, are reported by pharmacies to the state, which then posts the information on a website for prescribers and pharmacists.  It's a fantastic resource.  34 states have a monitoring program like this, but Florida does not.

We checked this database the moment the patient left our office.  The database didn't show any controlled substance prescriptions for him, because he misspelled his last name on his registration forms.  ON PURPOSE.  He knew we were going to check the database.  The fax from the pharmacy listed the patients birth date and name, but his last name was spelled differently.  We actually addressed the spelling issue when he checked in, because his wife's insurance card had a different spelling on it.  In addition, the patient conveniently had forgotten his driver's license, so we couldn't double-check his information against a legitimate form of ID.

We got a call from the pain management physician on Friday that the patient failed to show up for his appointment.  I will be discharging the patient from our practice next week.

Chronic pain is a problem for millions of people.  Narcotics are a mainstay of managing their pain.  The difference between compliant patients and the addict I describe above is that compliant patients are exactly that.  They keep appointments.  They allow the doctors to count their medicines.  They sign narcotic contracts.  They don't take advantage of the physician.

Two or three times a year we get new patients like this.  A few years ago, we had no way to check if we were being played by patients seeking inappropriate prescriptions.  The IPMP has changed the game.  Physicians can remain compassionate, without thinking every patient requesting a strong pain medicine is a drug seeker.  If we are suspicious, we can easily check to see if they are listed, and if their name doesn't come up, we can take care of them without concern.

Prescription monitoring programs should be in place in all 50 states.  There is no reason why physicians and pharmacies shouldn't have the ability to check for patients who abuse medicines.  The problem is, we aren't utilizing these resources like we should.  If we checked these databases on each and every patient, it would be a significant deterrent to stop this type of behavior.  If we could make it harder for them to get their fix, then maybe, with the grace of God, we could help them climb out of the hole of addiction.

Watson Computer, M.D.

It was announced this week that Watson, the IBM AI computer system that defeated human counterparts Ken Jennings and Brad Rutter on Jeopardy a few months ago, was "hired" by Columbia University Medical Center for a new challenge - diagnosing complex medical conditions.

It really isn't that surprising.  Physicians go through complex algorithms to diagnose patients, just like computers running code.  "Tell me what brings you in today", or "How long has this been going on?".  "Can you describe the pain?".  "Where is the pain located?".  "Does the pain radiate or travel?".   Those of you who are my patients are used to me going through these "checkdowns", to use a sports analogy.  We decide which pieces of data are important, and which can be discarded.  After a few minutes of asking questions and getting quality answers, we have formulated a short list of possibilities, called a differential diagnosis.  A physical exam adds in more data, pinpointing the diagnosis or eliminating certain diagnoses from the list. Finally, if we are unable to make a diagnosis, we may order some tests, like blood work or an xray.  Then, 95+% of the time, voila.  The patient is diagnosed, treated, and improves (hopefully).

A computer can be trained to go through the same algorithms, go through the same checkdowns, per se, and order the same tests. And I am sure they can make the same diagnoses as well, maybe even pushing our 95% success rate.  Despite this, Watson and his computer brethren aren't going to take over medicine any time soon.

A computer cannot do a physical exam.  A computer can't (yet) tell inflection of voice, get a sense that the patient is in obvious discomfort, or understand certain human behaviors.  A good example is a 20 year old male coming in to see me with his parents.  20 year old males normally don't come to the doctor, much less with their parents.  This is a subtle yet important piece of information, one I obtain the moment I walk in the exam room.  It changes the way I approach the visit.

I am sure that Watson will be fantastic at helping diagnose really complex patients.  But for every day medicine?  Not yet.  The art of medicine, to efficiently, compassionately and correctly diagnose and treat a patient is something which requires a human to human interaction, between the doctor and the patient.  Nowadays, patients can research symptoms on the Internet to "diagnose" themselves.  The problem is that they can't do it correctly.  Patients call our office, wanting treatment for pink eye, but when we see them, they really have allergic conjunctivitis.  Or, a patient thinks they have heartburn, but after we evaluate them, we diagnose them with angina, a telltale sign of heart disease.

One of my famous teaching points is that common things are common, uncommon things are uncommon, and rare things are rare.  The vast majority of what we see is common.  Doctors don't need to memorize all the esoteric data that Watson has in its neural net to practice medicine, we just need access to it. This is why physicians shouldn't feel threatened by Watson getting his medical degree.  We should embrace these technologies because the practice of medicine is a gray science, with endless variables.  It's never black and white, and it constantly changes.  6.4 billion human machines, all similar, but none the same.  Systems like Watson can help us find patterns in disease presentation across different populations, allowing us to better diagnose patients.

My practice has used computers since 1997, when we transitioned from a paper to an electronic medical record (EMR) system.  Our information systems keep our patient data organized, remind us when patients are due for screening tests, tell us if we accidentally prescribe a medicine to someone who is allergic, and, most importantly, makes sure our notes are legible.  I can't imagine practicing medicine without these tools.  They are unbelievably useful.  I think every medical practice should adopt these technologies to improve patient care, despite the fact that implementation can be cost-prohibitive.

I am looking forward to seeing what Watson can do.  But, at the end of the day, Watson can have his massive trove of medical knowledge.  I'll take my smaller, more useful noggin, my Dell server with our patient database, and Mr. Grzyb's amazing mini-kolackys at Christmas time.  Watson doesn't know what he's missing.

Lowdown on our slowdown

2011 has been disturbingly slow.  Through April, the number of patients I saw in the office was 140 less than in 2010.  That may not sound like a lot, but it's about 2 patients a day.  Add that up over the entire year, and it's real revenue we have to do without.

For those who aren't aware, here is an overview of my medical practice.  It is located in Naperville, IL, an upper middle class suburb southwest of Chicago, with a population of 160,000.  We have in excess of 6000 active charts (patients seen in the last 36 months), with a demographic breakdown of 20% pediatrics, 60% adults, and 20% Medicare (or patients aged 65+).  It is, in my opinion, what the prototypical family practice should look like.

Our office hours haven't changed at all. We are open Monday, Tuesday, Wednesday, and Friday 8 to 5, Thursday 11 to 8 pm, and Saturdays 8 am to 12 pm 2 out of 3 Saturdays.  We haven't decreased our support staff, so wait times on the phones are < 5 minutes, and typically < 2 minutes if you don't call between 8 and 9 am.

So the question is, why are our numbers down?  I have a number of theories.

First, pharmacy run clinics.  There is one located in the Walgreens up the street from our office.  These clinics are staffed by nurse practitioners, with evening and weekend hours.  Patients are choosing these clinics, paying a premium (usually around $75) for the "convenience" of walking in without an appointment, even if there is an hour or two wait.

Second, time off of work.  We have seen a significant increase in requests for appointments after 5 pm.  Patients simply won't take off work to come in when we have appointments.  What is amazing is that my Thursday evenings, when I work until 8 pm, are rarely booked out.  Same thing for our Saturdays.  People want to be seen on their way home from work (between 5 and 6 pm), or not at all.  My staff offers multiple appointments to these types of patients, with no luck.  They want to come in when they want to come in.

Third, out-of-pocket expenses.  Deductibles have risen to the point where people are choosing to "wait and see" when they get sick.  These acute care visits are the ones we've seen decrease - colds, coughs, headaches, etc.  These are the bread and butter visits of most primary care offices.  Higher deductibles, high unemployment, high fuel prices,  higher food prices; all of these have made patients think twice about what and how much they can/want to spend on healthcare.

Lastly, mediocre flu seasons.  We used to be able to bank on the January to March window to give us a healthy bump in visits because of influenza.  Not any more.  The H1N1 outbreak of 2009 changed everything (for reasons unknown).  Since that outbreak, we've had 2 straight uncharacteristically slow flu seasons, and thus, less sick visits.

We are coming into the busy, school physical time of our work year.  I am beginning to worry that the nurse-run, deep discount school physical clinics put on by companies like the Visiting Nurses Association are going to further dent our appointment base.  I'm going to post a blog at a later time about the real risk of these bogus school "physicals", which are really just appointments to complete forms for school.

It may seem counterintuitive, but these are the times when I am happy I own my practice.  I can't imagine what it's like for physicians who are "owned" or are part of large mega-groups when their numbers go south. The factors that have caused this decrease in patient visits aren't going to improve any time soon, and if we continue to see a deterioration in our visits, I have the ability to make adjustments in my overhead, unlike employed physicians.

Here is hoping (tongue-in-cheek) for a nice outbreak of influenza sometime soon.

Welcome!

I set up this blog in late 2009 with the idea that I wanted to start to write about healthcare. Well, I guess I wasn't ready at the time. In the 18+ months since I set up this account, there has been an avalanche of healthcare issues that have dominated the headlines, from the sweeping healthcare bill passed by Congress to rising insurance premiums. It's been a slow few weeks at the office, so I figured, heck, stop procrastinating and start writing.

I would like this blog to both educate and entertain. Healthcare is a massive, intimidating beast. I am going to try and pull back the Curtain of Oz for you, telling stories about the challenges, frustrations and joys of what it's like to practice medicine in today's world. Delivering high quality care to the masses is not easy, I can tell you that, but it's something I think is going to make for some good reading.

I am looking forward to your comments and replies. I will be enlisting the guidance of my fellow bloggers, so be patient with me if I make a mistake or two with blogging protocol. Don't be shy to share your opinions. That is how we, together, will make this work.

Thanks for taking a few minutes out of your week to follow along. Here we go...